What is the recommended evaluation and management of labial cysts (Bartholin gland cysts or epithelial inclusion cysts) in women?

Management of Labial Cysts

Bartholin Gland Cysts and Abscesses

For symptomatic Bartholin gland cysts or abscesses, perform fistulization (Word catheter placement) or marsupialization in the office setting, as these methods have similar healing and recurrence rates and are superior to simple incision and drainage. 1

Initial Assessment

• Distinguish between cyst and abscess: Abscesses present with significant pain, erythema, and fluctuance, while cysts are typically asymptomatic or minimally symptomatic unless enlarged 2, 1
• Rule out malignancy: In women over 40 years, consider biopsy of any suspicious masses, as malignant transformation, though rare, can occur 3
• Assess size and symptoms: Bartholin gland cysts affect 2% of women during their reproductive years and warrant treatment when symptomatic 1, 3

Treatment Algorithm

First-Line Office Procedures (Equal Efficacy)

The following procedures have similar healing and recurrence rates 1, 4:

• Word catheter placement (fistulization): After local anesthesia, make a small incision and insert the catheter, inflating the balloon with 2-3 mL of saline; leave in place for 4-6 weeks to allow epithelialization 5, 2, 1

  • Common pitfall: Premature catheter dislodgement before epithelialization leads to recurrence 5
  • Alternative technique: If Word catheter unavailable, use a small loop of plastic tubing secured to prevent expulsion 5

• Marsupialization: Create an incision, evacuate contents, and suture the cyst wall edges to the surrounding skin to create a permanent opening 2, 1, 3

  • This procedure can be performed in the office under local anesthesia 2

• Silver nitrate or alcohol sclerotherapy: These chemical ablation methods show comparable outcomes to surgical techniques 1, 4

Procedures to Avoid

• Simple incision and drainage: NOT recommended due to high recurrence rates compared to other methods 1
• Needle aspiration alone: NOT recommended due to increased recurrence risk 1

Adjunctive Management

• Antibiotics: Prescribe oral antibiotics for abscesses, particularly if surrounding cellulitis is present 5
• Pain control: Provide adequate analgesia during the healing period 2

When to Consider Excision

Complete surgical excision should be reserved for 3:

• Recurrent cysts despite multiple office procedures
• Suspicion of malignancy (especially in women >40 years)
• Patient preference after counseling on risks and benefits

Important caveat: Excision is more complicated, requires general anesthesia, and does not affect vaginal lubrication since other glands compensate 1, 3

Evidence Quality Note

Current randomized trial evidence shows no clear superiority of any single intervention, with all major techniques demonstrating similar recurrence rates 4. The choice between Word catheter and marsupialization can be based on provider experience and resource availability 1, 4.

Epithelial Inclusion Cysts

Epithelial inclusion cysts of the labia are typically benign and require treatment only when symptomatic; management consists of simple excision or incision with evacuation of contents. 6

Clinical Characteristics

• Presentation: Usually asymptomatic nodules containing cheesy keratinous material 6
• When inflamed: Present as painful, tender swellings that may mimic abscesses 6
• Pathophysiology: Inflammation occurs from cyst wall rupture and extrusion of contents into the dermis, not from primary infection 6

Management Approach

For Inflamed Cysts

• Incision and evacuation: Make an incision, thoroughly evacuate contents, probe the cavity to break up loculations, and cover with dry dressing 6
• Antibiotics rarely needed: Systemic antibiotics are unnecessary unless complicating factors exist, including 6:
  • Multiple lesions
  • Cutaneous gangrene
  • Severely impaired host defenses
  • Extensive surrounding cellulitis
  • Severe systemic manifestations of infection

For Asymptomatic Cysts

• Observation: Most asymptomatic cysts can be monitored without intervention 6
• Elective excision: Consider for cosmetic concerns or patient preference 6

Key Clinical Pitfall

Do not routinely culture or prescribe antibiotics for inflamed epithelial inclusion cysts, as inflammation is typically a sterile foreign body reaction to cyst contents rather than bacterial infection 6. Reserve antibiotics for cases with true secondary infection evidenced by extensive cellulitis or systemic signs 6.